Root Cause Analysis: ‘We can do better.’

By Susan Carr

Saying, “We can do better,” Jim Bagian declared that root cause analysis (RCA)—the subject of a new report by the National Patient Safety Foundation (NPSF)—offers uncommon potential to improve safety and that, in general, healthcare has not used it well and wasted opportunities to prevent future harm.

Bagian and Doug Bonacum were co-chairs of the working group that developed the new report for NPSF. They also led “Patient Safety Science: Successful Practices to Optimize Root Cause Analysis,” an all-day workshop offered the day before NPSF’s annual Patient Safety Congress, held earlier this year in Austin, Texas. With their time and lively discussion, those who attended the workshop endorsed Bagian’s sentiments about “doing better.”

Following introductions, the workshop began with attendees sharing their success stories and disappointments related to RCAs. Some described their organizations’ RCA processes as being well developed and effective, while others expressed frustrations related to poor training, inadequate leadership, and lack of follow up. Bagian and Bonacum identified action, improvement, and measurement as crucial components of RCAs and regretted that the name “root cause analysis” leaves out the most important steps.

The report, RCA²: Improving Root Cause Analyses and Actions to Prevent Harm, renames the process root cause analysis and action—“squaring” the A—and says that its only purpose is to prevent harm:

If actions resulting from an RCA² review are not implemented, or are not measured to determine their effectiveness in preventing harm, then the entire RCA² activity may be pointless. (p. 2)

The report, which was developed with support from The Doctors Company Foundation, is available for free download on the NPSF website. Jim Bagian and Doug Bonacum will discuss the report during a free webcast at 1 p.m. ET on Wed, July 15, 2015. Shortly thereafter, a recording of the webcast will be available on the report’s webpage.